Reducing primary postpartum haemorrhage in a low-resource country: a novel approach
Authors: Theresa Azonima Irinyenikan
Journal: The Lancet Global Health (2023)

According to the WHO maternal mortality report of 2015, approximately 303 000 women worldwide died during pregnancy because of childbirth complications, and almost all these deaths occurred in low-income or middle-income countries, with primary postpartum haemorrhage reported as the main cause of deaths.1WHOMaternal mortality: key facts.http://www.who.int/en/news-room/factsheets/detail/maternal-mortalityDate: 2018Date accessed: December 12, 2022Google Scholar In low-resource countries such as Niger, where 32% of maternal deaths are reported to result from primary postpartum haemorrhage,2Say L Chou D Gemmill A et al.Global causes of maternal death: a WHO systematic analysis.Lancet Glob Health. 2014; 2: e323-e333Summary Full Text Full Text PDF PubMed Scopus (3208) Google Scholar the need to address this public health issue is of great importance. It has also been reported that most of the maternal deaths resulting from primary postpartum haemorrhage occur within the first 24 h of birth, and the majority of these deaths could be avoided by the active management of the third stage of labour through the use of prophylactic uterotonics (where available) and other timely interventions.3WHOWHO recommendations for the prevention and treatment of postpartum haemorrhage. World Health Organization, Italy2012: 1-41Google Scholar, 4WHOWHO recommendations: uterotonics for the prevention of postpartum haemorrhage. World Health Organization, Geneva2018Google Scholar Several interventions have been proposed for reducing maternal mortality caused by primary postpartum haemorrhage globally, but such interventions have not yet adequately reduced maternal deaths from primary postpartum haemorrhage in low-resource countries.5Starrs AM Safe motherhood initiative: 20 years and counting.Lancet. 2006; 368: 1130-1132Summary Full Text Full Text PDF PubMed Scopus (149) Google Scholar, 6WHOWorld Health Report 2005: making every mother and child count. World Health Organization, Geneva2005Google Scholar Therefore, advocating for the three-step treatment strategy to reduce maternal mortality from primary postpartum haemorrhage in a severely resource-constrained country such as Niger, as reported in the study by Anders Seim and colleagues,7Seim AR Alassoum Z Souley I et al.The effects of a peripartum strategy to prevent and treat primary postpartum haemorrhage at health facilities in Niger: a longitudinal, 72-month study.Lancet Glob Health. 2023; 11: e287-e295Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar could be seen as a good step in improving the health care of women during childbirth, and an essential step towards the achievement of the Millennium Development Goals.5Starrs AM Safe motherhood initiative: 20 years and counting.Lancet. 2006; 368: 1130-1132Summary Full Text Full Text PDF PubMed Scopus (149) Google Scholar As described by the authors, the three-step treatment entails the use of 800 μg misoprostol followed by the insertion and inflation of an intrauterine condom tamponade. If bleeding continued, a non-inflatable anti-shock garment was applied and the patient was referred to hospital. This combined intervention produced immediate results, with each intervention showing some efficacy individually in severely under-resourced health facilities before a referral to larger hospitals. It is therefore technically reasonable that a systematically applied combination of these interventions can quickly reduce mortality associated with primary postpartum haemorrhage on a public health scale before a woman gets to a hospital. However, future initiatives might consider adding intramuscular oxytocin to these interventions, which has been recommended by WHO for the prevention of primary postpartum haemorrhage.8WHOWHO recommendation on routes of oxytocin administration for the prevention of postpartum haemorrhage after vaginal birth. World Health Organization, Geneva2020Google Scholar At the referral hospital, a further intervention that could be considered, especially if primary postpartum haemorrhage is caused by atony, could be other uterotonics, such as intravenous tranexamic acid, which studies have suggested could be useful in reducing primary postpartum haemorrhage (although it is not currently recommended by WHO for prevention of primary postpartum haemorrhage).9WHOWHO guidelines approved by the guidelines review committee. WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage. World Health Organization, Geneva2017Google Scholar, 10Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial.Lancet. 2017; 389: 2105-2116Summary Full Text Full Text PDF PubMed Scopus (847) Google Scholar The findings of this study, which showed that primary postpartum haemorrhage was reduced by half nationwide in Niger within a period of 2 years, suggest that using this low-cost intervention package would be useful in modern-day obstetric practice, both in Niger and other low-resource countries in west Africa. Using this novel intervention to prevent primary postpartum haemorrhage will help to reduce the economic burden of managing the morbidities associated with the condition, and it will help to reduce the overuse of the minimal resources in the health facilities, including human resources. It is an approach that could be adopted to save lives before a definitive treatment is accessible, thereby reducing the number of babies who have been orphaned as a result of this life-threatening condition. Given that primary postpartum haemorrhage mortality in Niger fell to less than half that of the average for eastern, western, southern, and southeastern Asia and northern African regions, and that the proportion of birth-related maternal deaths caused by primary postpartum haemorrhage in health facilities in this study is now on par with the USA (9·53% in Niger and 11% in USA),11Bienstock JL Eke AC Hueppchen NA Postpartum hemorrhage.N Engl J Med. 2021; 384: 1635-1645Crossref PubMed Scopus (67) Google Scholar the interventions described in this study can be of tremendous help in low-resource countries to curb the consequences of the morbidity and mortality associated with primary postpartum haemorrhage. This intervention package can be considered a standard operating procedure until randomised trials are carried out especially in low-resource countries. This approach will save lives, given the length of time and cost involved in conducting such randomised trials. The low cost associated with this intervention will help to improve the economy of low-resource countries, and will further help save more funds that could be used for other health interventions, such as childhood immunisation and the eradication of communicable diseases among the population. I declare no competing interests. The effects of a peripartum strategy to prevent and treat primary postpartum haemorrhage at health facilities in Niger: a longitudinal, 72-month studyPrimary postpartum haemorrhage morbidity and mortality declined rapidly nationwide. Because each treatment technology that was used has shown some efficacy when used alone, a strategic combination of these treatments can reasonably attain outcomes of this magnitude. Niger's strategy warrants testing in other low-income and perhaps some middle-income settings. Full-Text PDF Open Access